How to Treat Acne During Pregnancy
Some Medications May Be Safe, but It Is Important to Ask Your Doctor
The Essential Information
While most women experience improved acne symptoms during pregnancy, some experience acne flares, particularly in the third trimester.
Determining how to treat acne during pregnancy is challenging because there is little direct evidence concerning the safety of most acne medications during pregnancy, and some medications are contraindicated during pregnancy.
Topical medications, such as benzoyl peroxide, do exist, but it is important to discuss options with a doctor before starting on any medication, whether that medication be topical or oral. Because of limited options during pregnancy, many experts encourage pregnant women to aim for symptom improvement rather than complete clearing of acne during pregnancy.
Always Consult Your Doctor: If you are pregnant and have acne, consult your doctor before beginning treatment. Because many acne medications carry risk to the fetus, it is important that your doctor closely supervise your acne treatment during pregnancy. Always weigh the benefits of treatment against the risk of harming the fetus.
IMPORTANT: It is imperative to stop isotretinoin (Accutane) treatment at least one month before becoming pregnant in order to avoid the risk of severe birth defects and spontaneous abortion.
- The Effect that Pregnancy Has on Acne
- Treating Acne During Pregnancy
- Topical Treatments (Some Are Likely Safe and Some are Unsafe)
- Oral Antibiotics (Some Are Likely Safe and Some are Unsafe)
- Other Oral Treatments (Some Are Likely Safe and Some are Unsafe)
Understanding how to treat acne during pregnancy is difficult because there is no direct scientific evidence concerning the safety of most acne medications during pregnancy, and some common acne medications, such as isotretinoin and tetracycline antibiotics, are unsafe during pregnancy. While there are several good treatment options, mostly topical medications, such as benzoyl peroxide, it is important to discuss these options with a doctor and to weigh the benefits of treating acne against the risks to the fetus.
First, let's look at the effect that pregnancy has on acne and the challenges of treating acne during pregnancy. Then we will consider treatment options, along with their risks and benefits.
The Effect that Pregnancy Has on Acne
Pregnancy has an unpredictable effect on acne. Most women experience improvement in their acne during pregnancy. However, some women experience acne flares, post-inflammatory hyperpigmentation (red/dark skin once an acne lesion heals), truncal acne (acne on the chest and back), and even a first episode of acne while they are pregnant.1
Acne is a disease involving skin oil glands. Excessive skin oil can result in clogged pores and inflammatory lesions that characterize acne. Skin oil glands produce more skin oil during pregnancy, particularly during the third trimester. That's why, if acne flares during pregnancy, it normally happens usually during the third trimester.1
Treating Acne During Pregnancy
Determining how to treat acne during pregnancy is challenging. Scientists do not include pregnant women in clinical trials of acne medications because of the risk to the fetus. Therefore, there is no direct evidence concerning the safety of most acne medications during pregnancy.
According to a 2016 article in the Journal of the American Board of Family Medicine, "[M]ost treatment recommendations are based on observational and animal studies."3
Because there is little data available, women and their doctors need to set clear goals for acne treatment during pregnancy. Some researchers recommend aiming for symptom improvement rather than complete clearing of the skin during pregnancy.4
Despite the lack of research data, the FDA has established five risk categories for medications during pregnancy (see below). While this system guides us in medication choices, the best approach is to discuss options with a doctor and tailor the treatment according to the phase of pregnancy or breastfeeding.4
Topical Treatments (Some Are Likely Safe and Some are Unsafe)
For mild-to-moderate acne, topical treatments are the preferred first choices. Even for severe acne, topical medications can be effective. It is important to note that topical medications are not without risk because in some instances they can be absorbed through the skin and into the bloodstream, especially when used on large areas of skin for a considerable amount of time.3
The following topical medications likely are safe during pregnancy:
Benzoyl peroxide [Category C] demonstrates antibacterial, pore-unclogging, and anti-inflammatory properties, which can help clear acne. Theoretically, benzoyl peroxide poses only a small risk to the fetus. While it is absorbed into the skin, the kidneys quickly remove it from the bloodstream.
According to a 2016 article in the Journal of the American Board of Family Medicine, "Benzoyl peroxide is considered safe during pregnancy."3
Salicylic acid [Category C] slows down shedding of the cells inside the follicles, which helps prevent clogging. It also helps break down blackheads and whiteheads. Salicylic acid is absorbed into the skin and applying it to large areas of skin can be toxic. However, risk is low during pregnancy as long as it is not used on large areas of the skin for long periods of time.
Topical antibiotics, such as clindamycin [Category B] and erythromycin [Category B], prevent the growth of acne bacteria and reduce acne inflammation, and are normally prescribed alongside benzoyl peroxide.
According to a 2016 article in the Journal of the American Board of Family Medicine, "Topical antibiotics have long been used for the treatment of inflammatory acne; erythromycin and clindamycin are the 2 most commonly prescribed agents. Both are classified as pregnancy category B. Short-term use of topical erythromycin and clindamycin is safe during pregnancy."3 These medications are more effective when used along with benzoyl peroxide.
Azelaic acid [Category B] also possesses antibacterial, pore-unclogging, and mild anti-inflammatory properties. In animal studies, azelaic acid does not harm the fetus. However, there are no human studies concerning the safety of azelaic acid during pregnancy, so it is wise to be cautious when using it during pregnancy.
Nicotinamide [Category not assigned by FDA] is related to vitamin B3 and is present in our diets. Topical use of nicotinamide appears to be safe. However, manufacturers advise caution during the first trimester.3
The following topical medications may not be safe and are not advised during pregnancy:
Topical retinoids, such as adapalene [Category C], tretinoin [Category C], and tazarotene [Category X], are common acne medications, but they should be avoided during pregnancy. Tazorotene in particular can harm the fetus and should never be used during pregnancy. Adapalene and tretinoin unlikely are to harm the fetus because only small amounts are absorbed into the skin, but experts recommend avoiding them during pregnancy because there is not consensus among researchers concerning their safety.
Dapsone [Category C] is antibacterial and anti-inflammatory. So far, there is no evidence that dapsone presents a risk to the fetus. However, it is a newer medication, and there is a lack of research concerning its safety during pregnancy. Researchers advise that women use it only when the benefits clearly outweigh the risks.3
Oral Antibiotics (Some Are Likely Safe and Some are Unsafe)
Historically, oral treatment during pregnancy generally was reserved for women who had moderate-to-severe inflammatory acne that had failed to respond topical treatment.3 However, many of these recommendations are from the 1970s. Today we have many topical treatments, such as benzoyl peroxide, which works better than any oral antibiotic and without the side effects. Regardless, let's look at which oral treatments are suitable for pregnant women.
Oral antibiotics improve acne because they prevent the growth of acne bacteria, and they reduce inflammation. However, oral antibiotics are only somewhat effective in treating acne since they do not clear the skin. In addition, oral antibiotics lead to antibiotic resistance, a phenomenon in which bacteria stop responding to the antibiotic, and the antibiotic loses its ability to kill the bacteria. Antibiotic resistance is a worldwide problem that is made worse by over-prescribing antibiotics. Oral antibiotics also can come with side effects such as cramping and diarrhea. For these reasons, oral antibiotics should be taken for a maximum of six months. During pregnancy, oral antibiotics should be prescribed only when there is a clear need, and all other options fail. And if possible, they should be avoided during the first trimester.3,4
The following oral antibiotics likely are safe during pregnancy:
- Erythromycin [Category B] is the oral antibiotic of choice during pregnancy. However, there is no research concerning the safety of long-term use during pregnancy.
- Azithromycin [Category B] also is sometimes prescribed during pregnancy. However, there is less information about its safety during pregnancy than there is about erythromycin.
- Cephalexin [Category B] can be used during pregnancy. However, scientists are concerned about the possibility of resistance against Staphylococcus strains of bacteria, some of which can cause life-threatening infections.
- Clindamycin [Category B] normally is prescribed as a topical antibiotic, but in this case, we are referring to oral clindamycin. It can be an effective acne treatment, and it appears to be safe to use during the first trimester. However, it is a known cause of antibiotic-associated diarrhea, which can be life threatening.2-4
The following oral antibiotics should not be taken during pregnancy:
- The tetracycline antibiotics (doxycycline, tetracycline, and minocycline) [All are Category D] are the most commonly prescribed oral antibiotics for acne. However, they should never be used during pregnancy, especially after the first trimester because they are known to be toxic during pregnancy.
- Trimethoprim [Category C] is recommended during pregnancy only when there are no other options, and the benefits outweigh the risks, because research has shown an association between trimethoprim use and miscarriage during the first trimester.2-4
Other Oral Treatments (Some Are Likely Safe and Some are Unsafe)
The following other oral treatments likely are safe during pregnancy:
Oral zinc is another treatment option for mild to moderate acne during pregnancy. Zinc may reduce the production of skin oil and is antibacterial and anti-inflammatory. Topical zinc has not been shown to be effective against acne, however. Oral zinc can be taken alone or in combination with other treatments, but the maximum amount of zinc that should be taken during pregnancy is 11 mg/day. Zinc may cause nausea and vomiting if taken on an empty stomach.2,3
The following other oral treatments are unsafe during pregnancy:
Oral corticosteroids, such as prednisone [Category C], are potent medications that can treat severe acne, especially when both topical medications and oral antibiotics fail. However, research has shown that prednisone can cause severe birth defects as well as a slight increase in the risk of miscarriage. In addition, using corticosteroids repeatedly or long-term during pregnancy can cause growth failure of the fetus that results in the baby's being born at a low weight. Therefore, oral corticosteroids should be used only for exceptionally severe acne, after the first trimester, for less than one month, and under close medical supervision.2,3
Anti-androgens, such as spironolactone [Category C], are medications that suppress androgens (male hormones that are present in both males and females). These medications can reduce skin oil production and improve acne. However, they should never be used during pregnancy because there is a risk that they cause feminization of a male fetus.2,4
Isotretinoin (Accutane) [WARNING: CAUSE SEVERE BIRTH DEFECTS]
Oral retinoid medications such as isotretinoin (Accutane) [Category X] are contraindicated during pregnancy because they can cause spontaneous abortions and severe birth defects. This risk is severe enough that women must stop isotretinoin treatment at least one month before becoming pregnant, and many countries require women taking isotretinoin to join pregnancy prevention programs.2-4
According to a 2013 article in the American Journal of Clinical Dermatology, "Women should be aware that they should not become pregnant 1 month before, during, or for 1 month after taking isotretinoin."2 Manufacturers have put warnings on isotretinoin labels, and both manufacturers and governments have implemented risk management programs to help women avoid pregnancy while taking isotretinoin.5 Recent studies have shown that failure to use adequate contraception is the primary reason for pregnancy during isotretinoin treatment and that compliance with pregnancy prevention programs is low.
According to a 2016 article in the Canadian Medical Association Journal, "Internationally, between 7% and 60% of female users [of isotretinoin] have been found not to use any form of contraception during treatment. As many as 80% do not use 2 methods of birth control, as recommended."6
The following table summarizes which medications likely are safe during pregnancy and which ones are not:
- Yang, C. S., Teeple, M, Muglia. J. & Robison-Bostom, L. Inflammatory and glandular skin disease in pregnancy. Clin Dermatol 34, 335 - 343 (2016). https://www.ncbi.nlm.nih.gov/pubmed/27265071
- Meredith, F. M. & Ormerod, A. D. The management of acne vulgaris in pregnancy. Am J Clin Dermatol 14, 351 - 358 (2013). https://www.ncbi.nlm.nih.gov/pubmed/23996075
- Chien, A. L., Rainer, B., Sachs, D. L. & Helfrich, Y. R. Treatment of acne in pregnancy. J Am Board Fam Med 29, 254 - 262 (2016). https://www.ncbi.nlm.nih.gov/pubmed/26957383
- Pugashetti, R. & Shinkai, K. Treatment of acne vulgaris in pregnant patients. Dermatol Ther 26, 302 - 311 (2013). https://www.ncbi.nlm.nih.gov/pubmed/23914887
- Abroms, L., Maibach, E., Lyon-Daniel, K. & Feldman, S. R. What is the best approach to reducing birth defects associated with isotretinoin? PLoS Med 3, e483 (2006). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1637125/
- Henry, D. et al. Occurrence of pregnancy and pregnancy outcomes during isotretinoin therapy. CMAJ 188, 723 - 730 (2016). https://www.ncbi.nlm.nih.gov/pubmed/27114489
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